post-pericardiotomy syndrome.may 22.pptx

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Post-Pericardiotomy SyndromeJoy Baysa, MD, PGY-4

May 22, 2013


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Lets Meet the Patient

11 yo previously healthy male who initially presentedwith fever of unknown origin and non-tender rash

on his hands and feet Echocardiogram revealed endocarditis of his mitralvalve with a mobile vegetation

Subsequently went to the OR for removal of infectedvalve and implantation of 25 mm St Judes valve inthe mitral position

PCR positive for hemophilus paraphrophiilus Discharged home on POD# 13 on IV Rocephin and

anti-coagulation with Coumadin


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About 6 weeks post-operatively, patient presented incardiology clinic for follow-up

Had complaints of cough, decreased appetite, and

increased fatigue for the past few days Noted in clinic to be tachycardic to the 110s-120s

No fevers or chest pain


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Labwork

12.6

12.1

34.9

275

77N/13L/10M

ESR: 33

CRP: 10

INR: 2.37

PT: 26.7

PTT 55.9

135

3.9

128

100

26

10

0.4


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CXR

CXR 6 weeks priorAdmission CXR


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Echocardiogram


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Management & Hospital Course

Patient was admitted to the CICU The next morning, he was taken to the cath lab for

pericardiocentesis About 100 ml of bloody fluid was drained & sent

down to the laboratory for further evaluation andtesting

A pericardial drain was left in place for


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Post-Pericardiotomy Syndrome

An inflammatory process affecting the pleuraland pericardial space in 10-40% of patients aftersurgical trauma involving the pleura and/orpericardium

Also associated with other kinds of interventions

that may lead to pericardial bleeding, such aspacemaker implantation, percutaneous coronaryinterventions, and radiofrequency ablations


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Pathogenesis Historical Perspectives

First described by Janton in 1952 and Soloff in 1953after mitral commissurotomy

Was thought to be reactivation of rheumatic fever,

involving the mitral valve In 1958, Ito and colleagues noted the same process,

following surgical repair for congenital heart disease Because the common feature of these patients was

incision of the pericardium, they suggested the

name postpericardiotomy syndrome In the 1960s, several investigators noted that

elevated autoantibodies to the heart seemed to becorrelated with the manifestation of the syndrome


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Pathogenesis Contemporary Perspectives

Pathogenesis is still not well-understood Presumed to be an immune-mediated response after

damage to the pericardium or pleura, especially with

bleeding into the pericardial sac Supported by the fact that there is usually a latent period ofseveral weeks after initial insult (surgery) before symptomsappear

Also appears to respond to anti-inflammatory drugs However, PPS can also occur in immunosuppressed

transplanted patients Viral infections may play a causative or provocative role

There are seasonal variations in the syndrome, similar toseasonal variations in viral prevalence

The role of antiheart antibodies remains controversial


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Clinical Manifestations

80% occur in the first month

Pleuritic chest pain (56%)

Fever (50%)

Elevation of inflammatory markers (>70%)

Pericardial or pleural friction rub (1/3)

Pericardial or pleural effusion (~90%) Other manifestations: dyspnea, non-productive

cough, fatigue, myalgia/arthralgia


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Evaluation & Diagnosis

No standardized guidelines for diagnosis, whichprobably leads to underestimation

The largest clinical trials use the following criteria (2of the 5 are required to make the clinical diagnosis):

Fever beyond the first post-operative week with noevidence of infection

Pleuritic chest pain Pleural or pericardial friction rub

Pleural effusion

New or worsening pericardial effusion


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Laboratory studies show non-specific markers ofincreased inflammation CBC may show leukocytosis with predominance of

neutrophils ESR/CRP may be elevated

Blood and fluid cultures important in ruling outbacterial infection as cause rather than post-pericardiotomy syndrome

CXR may show cardiomegaly and/or evidence of

pleural effusions Echocardiography good for evaluating for thepresence of pericardial effusion


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Differential Diagnosis

Bacterial Pericarditis

Idiopathic/Viral Pericarditis

Hemopericardium

Bacterial Endocarditis

Incisional Pain

Pneumonia


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Treatment

Treatment is mostly aimed at patient comfort, as the illness isusually self-limited

Thoracentesis or pericardiocentesis not usually required,unless fluid is causing hemodynamic compromise, severe

symptoms, or is refractory to medical treatment Medical treatment is empiric, and involves the use of anti-inflammatory agents, such as NSAIDs or corticosteroids

Aspirin, at anti-inflammatory doses, usually used first line If ASA is contraindicated, can used ibuprofen Corticosteroids, at low-medium doses, may be useful in

refractory cases or if the patient is on anti-coagulant therapy Colchicine is emerging as an adjunct therapy as well as in

prevention of PPS


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Prognosis

Generally good prognosis, comparable to orbetter than that for idiopathic pericarditis


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Conclusion

Post-pericardiotomy syndrome is a relativelycommon complication of heart surgery

Occurs after pericardial or pleural incision, withbleeding into the pericardial space

Pathogenesis is not well understood but is thoughtto be an immune mediated process

Patients present with chest pain, fever, friction rub,and evidence of pericardial or pleural effusions May treat empirically with anti-inflammatory

agents, but illness is self-limited with generally goodprognosis


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References Imazio M, Brucato A, Rovere ME, et al. Contemporary features, risk factors,

and prognosis of the post-pericardiotomy syndrome. Am J Cardiol2011;108:1183-1187

Imazio M. The post-pericardiotomy syndrome. Curr Opin Pulm Med2012,18: 366-374.

Ito T, Engle MA, Goldberg H. Postpericardiotomy syndrome followingsurgery for nonrheumatic heart disease. Circulation 1953; 17: 549-556.

Kahn AH. The postcardiac injury syndromes. Clin Cardiol1992; 15: 67-72. Kirsh MM, McInotish K, Kahn DR, Sloan H. Postpericardiotomy

syndromes.Ann Thor Surg 1970; 9: 158-179.

Maisch B, Seferovic PM, Ristic AD, et al. Task Force of the Diagnosis andManagement of Pericardial Diseases of the European Society of Cardiology.Guidelines on the diagnosis and magament of pericardial diseases exectivesummary; the task force of the diagnosis and management of pericardialdiseases of the European Society of Cardiology.Eur Heart J2004; 25: 587-610.

post-pericardiotomy syndrome.may 22.pptx

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